Case Challenge #2

HPI: A 50 year old woman presents to the ER complaining of severe left-sided facial pain and swelling. The symptoms began 2 weeks prior with URI symptoms (fevers, runny nose, sinus congestion) and she was seen at another hospital and given augmentin, levofloxacin and dexamethasone with minimal improvement in symptoms. The pain and swelling have progressed in intensity and now she reports periorbital pain and blurry vision.

ROS: Positive for subjective fever, blurred vision (L>R eye), pain and redness of L eye, burning facial pain. Denies cough, chills, night sweats, weight loss, chest pain

PMH: HTN and DM2 (both diagnosed in the last month in the setting of recent illness)

PSH: no surgeries

Social: No recent travel or sick contacts. No tobacco or illicit drug use. Occasional alcohol use

Allergies: NKDA

Outpatient Rx: dexamethasone, levofloxacin, augmentin

PE: Temp 37.1C, HR 104 (regular), BP 114/52, SpO2 100% on RA

General: awake and alert, in no distress

HEENT: Left face with tender periorbital induration and edema extending to corner of mouth. Left proptosis and ptosis. Left pupil fixed and dilated with no extra-ocular motor function on left. Right eye normal in appearance. Right pupil reactive and EOM intact. Oral mucosa moist with left-sided pallor. Left posterior nare with small black eschar. No lymphadenopathy, thyroid not enlarged, no carotid bruits.

CV: unremarkable

Resp: unremarkable

Abdomen: unremarkable

Neuro: Absent fine/gross touch sensation over V1 and V2 distribution on left face. Left eye without response to light or threat. Right eye 20/20. No extraocular movements of left eye, normal EOM on right.

Data:

Slide1

Contrast enhanced MRI brain obtained in the ER is shown below (with positive arrow signs!)

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One thought on “Case Challenge #2”

  1. The case is one of a previously healthy 50 yo F presenting with symptoms of sinusitis in the setting of a suspected URI and was treated with Dexamethasone (immunosuppressive) and Broad spectrum antibiotics (Augmentin and Levaquin). The patient is diagnosed with diabetes (clearly uncontrolled with A1c of 13). The steroids either induced this or made worse and underlying condition. After initial management, the patients symptoms of sinusitis continue to worsen significantly and we are told on exam that the patient has small black eschar in the nare (a key clue) in addition to other facial and orbital findings. The patients labs are suggestive of diabetes ketoacidosis, there does not seem to be neutropenia and the patient is HIV negative. With the risk factors of uncontrolled diabetes with ketoacidosis, recent immunosupressive agent (Dex) and broad spectrum antibiotics exposure and the exam findings especially the black eschar, this patient likely has rhinocerebral mucormycosis until proven otherwise. The MRI findings are suggestive of left cavernous sinus thrombosis which has also affected blood flow in the internal carotid arteries when compared to the right side. This vascular involvement of the cavernous sinus and internal carotid artery can be seen with rhinocerebral mucormycosis. This patient’s immediate needs are therefore immediate antifungal treatment with Amphotericin as well as surgery involvement for debridement (in this case neurosurgery).

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